Davies Clinic Auto Payment Authorization Form
The following authorizing signature does hereby authorize Davies Clinic, PC to debit the listed
credit/debit card for the monthly payment indicated and to credit the account listed below. A request
must be submitted in writing to revoke this authorization.
Patient Name: _________________________________________________________________________
Credit Card Type: ______________________________________________________________________
Credit Card Number: ____________________________________________________________________
Expiration Date: _______________________________________________________________________
Security Code if available (three-digit code on back of card): ____________________________________
Name on Card: ________________________________________________________________________
Monthly Payment Amount: $ _____________________________________________________________
Monthly Payment Date: ________________________________________________________________
Name and Phone Number of Person Authorizing: _____________________________________________
Receipt:
Yes
No
Address to Mail Receipt (if different than account address):
_____________________________________________________________________________________
Authorizing Signature: __________________________________________________________________
Date: ________________________________________________________________________________
Upon completion, please return this form to:
Davies Clinic - Billing
345 N Grant St
Canby, OR 97013
If you have any questions regarding this form, please contact the billing office at 503.266.7600.